| PRINCIPAL'S NAME: |
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| Title: |
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| Company name: |
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| Street Address: |
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| City / Town: |
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| State / Province: |
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| Zip / Postal Code: |
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| Telephone Number: |
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| Cellular Phone: |
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| Fax: |
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| Email: |
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Start-up |
Existing Business |
Years in Business: |
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Sole Proprietorship |
Partnership |
Corporation |
| Industry: |
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| Amount of Financing Requested: |
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| Purpose of Financing: |
Franchise Purpose |
Equipment Financing |
Start-up Financing |
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Working Capital |
Receivables Financing |
Factoring |
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Other (Please Specify): |
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| Briefly Describe the purpose of Financing: |
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| Personal Guarantees Available: |
Yes No |
| Credit History of Owner: |
Excellent |
Satisfactory |
Poor |
| Credit History of Company: |
Excellent |
Satisfactory |
Poor |
| If a Business Purchase: |
Purchase Price $ |
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Cash Invested by Buyer$ |
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Total Business Assets $ |
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Total Liabilities $ |
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Total Business Net Worth $ |
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Company's Annual Revenue $ |
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Company's Annual Profit $ |
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| How did you hear about this email application? |
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To transmit this application, insert the E-mail address of your Business Finance Consultant here
(From original advertising or business card of your Business Finance Consultant).
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